Provider Attitudes and Perceptions of Family Interventions for Early Psychosis: Informing Competency-Based Training and Implementation
Cheryl Y. S. Foo (1,2,3), Catherine Leonard (1), Kelsey A. Johnson (3,4), Shirley M. Glynn (5), Lisa Dixon (3,6,7), Dost Ongur (2,3,8), Kim T. Mueser (1,6*), Corinne Cather (1,2*)
1. Center of Excellence for Psychosocial and Systemic Research, Department of Psychiatry, Massachusetts General Hospital
2. of Psychiatry, Harvard Medical School
3. Laboratory for Early Psychosis (LEAP) Center
4. Massachusetts Psychosis Network for Early Treatment (MAPNET), Beth Israel Deaconess Medical Center
5. Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles
6. Division of Behavioral Health Services and Policy Research, Department of Psychiatry, Columbia University Medical Center
7. Center for Practice Innovations, New York State Psychiatric Institute
8. Schizophrenia and Bipolar Disorder Research Program, McLean Hospital
9. Center for Psychiatric Rehabilitation, Boston University
* Co-senior authors
Background: Family interventions for psychosis (FIP; e.g., psychoeducation, single family, or multifamily group) is a defining element of first-episode psychosis (FEP) coordinated specialty care (CSC) programs, but have low adoption rates and are implemented with variable fidelity. Providers’ lack of buy-in and confidence in providing evidence-based treatments compromise implementation in real world settings. We examined CSC provider attitudes towards and confidence in providing FIP, and their associations with FIP fidelity and training.
Method: Providers from FEP CSC programs in Massachusetts completed an attitude survey comprising three subscales: 1) perceived effectiveness of FIP, 2) perceived impact of family involvement on client’s treatment; 3) stigma related to working with families. Providers also rated their comfort level and skill in working with families. Total and subscale scores on attitudes and confidence scales were correlated with team-level fidelity ratings on type and level of family involvement (i.e., provision and training in evidence-based FIP; most families involved in initial assessment; frequent family contact) (adapted FEP Fidelity Scale 2.0; Addington et al. 2020). We identified provider characteristics (years of experience, role, training received, type of interventions used in practice) associated with provider attitudes towards FIP, and confidence in competently delivering FIP. Providers were asked to identify priority areas for training and challenges to working with families in CSC.
Results: 52 providers from nine programs participated in this study (M= 39 years; 73% female; 56% white; 12% Hispanic/Latine; mean clinical experience: 4 years; 40% providing FIP). More positive FIP attitude was correlated with higher FIP fidelity (r=.29, p=.04). Provider perception of FIP effectiveness (r=.23, p=.10) and perceived positive impact of family involvement on client’s treatment (r=.37, p=.01) was significantly correlated with FIP fidelity. Stigma related to working with families was not associated with FIP fidelity. Compared to other clinical team members, peer specialists had significantly less positive attitudes towards FIP (mean difference range: -0.55 to -0.77; ANOVA effect size: .39; p <.001) and perceived more negative impacts of family involvement on client care (mean difference: -0.96 to -1.1; effect size: .32; p=.007). Among clinicians who do not provide FIP (n=31), those with prior training in evidence-based family interventions (n=6) had greater confidence in collaborating with families than those without FIP training (mean difference (SE): 0.49 (.25); d= .89; p=.06). Over a quarter of providers identified families’ unrealistic expectations about treatment and recovery and balancing client autonomy and confidentiality with family involvement as the most challenging aspects of working with families in CSC. Providers requested additional training on evidence-based FIP and supervision on navigating these challenges.
Conclusions: Providers with more positive attitudes about FIP belonged to programs with higher FIP fidelity. Further work is needed to understand the finding that peer specialists had more negative attitudes towards family involvement than clinical team members. Ongoing training and supervision for the whole team could improve provider attitudes towards FIP and competency in navigating unique challenges of working with families in team-based FEP care.